INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 12, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, GAUDENZIA INC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
On May 5, 2016, a review of personnel records was conducted. During the review, it was discovered that the facility had an unusual incident occur on February 2, 2016, which involved allegations of a staff member inappropriately touching a client and making inappropriate comments towards that same client. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory 3 business day timeframe.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
The Program Director will review the Unusual Incident Reporting Policy with all staff members.
The Program Director and Program Supervisor will review all facility Incident Reports, and will ensure that an Unusual Incident Report is filed, within 3 business days, with the Department for any incident as required per regulation.
On 5/5/16, an Unusual Incident Report was completed and filed with the Department for the February 2, 2016 incident. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, #2, 3, and 10, the facility failed to document a psychosocial evaluations in client records as of the date of the licensing inspection.
#2 was admitted on 04/28/2016 and was still an active client at the time of the inspection.
#3 was admitted on 05/07/2016 and was still an active client at the time of the inspection.
#10 was admitted on 02/23/2016 and was discharged on 03/08/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The psychosocial evaluation for client #2 was completed on 5/12/16, and is still an active client.
The psychosocial evaluation for client #3 was completed on 5/14/16, and discharged on 5/19/16.
The Program Supervisor will review the policy on Psychosocial Evaluations with the clinical staff by 5/20/16.
The Program Supervisor will complete a weekly chart review for all active clients to ensure Psychosocial Evaluations are completed per regulations.
The Program Director will meet with the Program Supervisor weekly to evaluate compliance. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, #3 and 8 the facility failed to document a preliminary treatment plan in the client records.
#3 was admitted on 05/07/2016 and was still an active client at the time of the inspection.
#8 was admitted on 04/16/2016 and was discharged on 04/27/2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Supervisor will review the regulation on Preliminary Treatment and Rehabilitation Plans with the clinical staff by 5/20/16.
The Program Supervisor will review counselor assignments for all new admissions daily with the clinical staff, and will ensure the completion of the Preliminary Treatment and Rehabilitation Plan per regulation.
The Program Supervisor will conduct weekly chart reviews to ensure full compliance with documentation requirements and review progress with the Program Director weekly. |
709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include record of services, progress notes, and discharge summaries, in client records, #2, 3, 5, 6, 8, and 9.
#2 was admitted on 04/28/2016 and was still an active client at the time of the inspection. The client record did not contain a record of services.
#3 was admitted on 05/07/2016 and was still an active client at the time of the inspection. The client record did not contain a record of services and did not have any clinical progress notes documented as of the date of the inspection.
#5 was admitted on 11/18/2015 and was discharged on 01/07/2016. The client record did not contain a record of services and there was no discharge summary documented as of the date of the inspection.
#6 was admitted on 12/29/2015 and was discharged on 02/12/2016. The client record did not contain a record of services.
#8 was admitted on 04/16/2016 and was discharged on 04/27/2016. The client record did not contain a record of services and did not have any clinical progress notes documented as of the date of the inspection.
#9 was admitted on 04/18/2016 and was discharged on 04/28/2016. The client record did not contain a record of services and did not have any clinical progress notes documented as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The record of services was completed for client #2 on 5/12/16, and the client remains active.
Client # 3 was discharged on 5/19/16.
The Program Supervisor will review all clinical documentation requirements with the clinical staff by 5/20/16, which will include the regulations on Record of Services, Progress Notes, and Discharge Summaries.
The Program Supervisor will conduct a weekly chart review on all active clients to ensure full compliance with clinical documentation requirements.
The Program Supervisor will review progress with the Program Director weekly.
Additionally, a Clinical Record Keeping Training will be scheduled for the clinical staff by 6/30/16. |